Standards for medical device connectors

Recently a tragic mix up where oxygen tubing was connected to a urinary catheter resulted in the death of ex-Socceroo Steve Herczeg (see here).

‘How can anyone make this mistake?’

Unfortunately events like this occur regularly – we often only hear of them via the media – our error report systems lacking transparency (see here).

This link from the FDA (see here) documents numerous similar mis-connections.

We are all human and we will always make mistakes. Those who build a safety system that depends on an absence of human mistakes will fail utterly.

We can and should design our equipment based on an international standard to reduce the likelihood of misconnection.

The International Organisation for Standardization recently released a set of standards for connectors (see here and see here)- we must ensure that this is introduced worldwide as soon as possible.

International standards and colour coding has been implemented for enteral feeding devices (see here, and here) in some countries but not others. We welcome and support their universal adoption.

In March 2017 the ACQSHC released a joint statement on introducing standard connectors for neuraxial medication (see here). We are unsure of a timeframe for implementation.


  1. Dr.Mandeep Kaur

    This kind of mistake is ridiculous.


      Unfortunately we are all humans and as humans we will always make mistakes. These misconnections occur with regular frequency. What is most ridiculous is that we do not redesign our equipment to prevent these mistakes from leading to adverse events.

  2. This truly is the worst example of a medical mistake I have heard yet, and could only be made in the new Liverpool Care Pathway atmosphere of ill trained staff and doctors. Why should we train someone to cure when the object is a eugenics protocol? It is happening all over the USA right now, and the mistakes are becoming more horrific and more ridiculous. However, you are correct about the changes that need to be made. It would be interesting to see what proportion of these mistakes are made on the elderly and disabled.

  3. Was there any root cause analysis done on this? A full report will be interesting to read for sharing important insights and lessons learned. Please email me any such info if available


      Hi Jignesh,
      I have seen the coroners case report:

      Unfortunately the recommendations after the coroners report will do little if anything to prevent the same adverse event from happening again.

      If there is a root cause it is that all humans make mistakes – we can’t change this human condition, however we can change the conditions humans work within. It cannot be ruled out that the patient accidentaly connected the oxygen tubing to his own urinary catheter. If we work together we should be able to design connections to make this physically impossible.

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